IQVIA Benefits Handbook
ADVERSE BENEFIT DETERMINATION
An "adverse benefit determination" is: (1) a denial, reduction or termination of a benefit; (2) a failure to provide or pay for a benefit (in whole or in part); (3) a denial of participation in the plan. For health coverage, an adverse benefit determination also includes a pre-service claim denial on the grounds that the treatment is experimental or investigational or not medically necessary and concurrent care determinations.
In the event of an adverse benefit determination, the claimant will receive notice of the determination. The notice will include the following:
  • The specific reasons for the adverse determination.
  • The specific plan provisions on which the determination is based.
  • A request for any additional information needed to reconsider the claim and the reason this information is needed.
  • If applicable, a description of the plan's review procedures and the time limits applicable to such procedures.
  • A statement of the claimant's right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review.
  • If any internal rules, guidelines, protocols or similar criteria were used as a basis for the adverse determination by a group health plan or a plan providing disability benefits, either the specific rule, guideline, protocol or other similar criteria or a statement that a copy of such information will be made available free of charge upon request.
  • For adverse determinations based on medical necessity, experimental treatment or other similar exclusions or limits under a group health plan or a plan providing disability benefits, an explanation of the scientific or clinical judgment used in the decision, or a statement that an explanation will be provided free of charge upon request.
  • For adverse determinations involving urgent care, a description of the expedited review process for such claims. (This notice can be provided orally within the timeframe for the expedited process, as long as written notice is provided no later than three days after the oral notice.)
  • For adverse determinations of benefits based on a determination of disability, an explanation of the decision, including an explanation of the basis for disagreeing with or not following:
    • The views presented by the claimant to the plan of health care professionals treating the claimant and vocational professionals who evaluated the claimant;
    • The views of medical or vocational experts whose advice was obtained on behalf of the plan in connection with a claimant's adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination; and
    • A disability determination regarding the claimant presented by the claimant to the plan made by the Social Security Administration.
Except as specifically provided otherwise, all determination notices may be provided in written or electronic form. Determination notices based on a determination of disability must be provided in a culturally and linguistically appropriate manner.